Author: Lorenzo De Min
Last update: 25/09/2019
Worldwide, rotavirus is the leading cause of acute gastroenteritis, an inflammation of the stomach and the intestines, in children up to five years of age. Within this age group, rotavirus was estimated to cause 120,000 to 215,000 deaths per year globally in 2017 (Clark et al., 2017). Rotavirus infection is ubiquitous, involving both low and high-income settings; however, data from 2013 reflects that four countries alone—India, Nigeria, Pakistan, and the Democratic Republic of the Congo—accounted for 49% of all deaths attributed to complications of rotavirus infection (WHO, 2016). A majority of children worldwide have contracted the infection at least once by the age of five, but children living in less developed areas have a higher risk of exposure (Esona & Gautam, 2015). The risk is heightened by limited water storage/delivery and sanitation infrastructure—challenges that are prevalent in complex emergency situations (e.g., after a natural disaster like an earthquake) and in camp settings or informal settlements. As such, migrants in transit camps, refugee camps, and urban informal settlements may be at particular risk of contracting rotavirus infection. Given the nature of rotavirus infection and its associated symptomatology, deaths associated with rotavirus could be drastically reduced with the implementation of preventive measures (Abou-Nader et al., 2018). Transmission of the virus is predominantly by faecal oral route (i.e. accidental ingestion of faecal material). Food, water, contaminated hands, and contaminated objects support spread of the infection and generally reflect absence of hygienic norms. Access to clean water and improved sanitation (e.g., toilet facilities with closed waste disposal systems), hand-washing with soap, and good personal and food hygiene are crucial to prevent transmission (WHO, 2017). Children between the ages of 3 and 12 months are at higher risk of contracting rotavirus infections; while infants are protected by maternal antibodies against infection within the first three months of life, such protection gradually wears off, leaving young children at higher risk. Exposure to rotavirus leads the body to progressively develop immune protection, leading to less severe infections in case of new contacts with the virus. For this reason, adults infected by rotavirus typically manifest mild symptoms or are asymptomatic. Asymptomatic individuals can spread the virus to others, however, which represents a source of risk for the community (Esona & Gautam, 2015). Clinical signs of the infection can vary widely in terms of severity, depending on qualitative and quantitative characteristics of the virus and strength of the host’s immune system. Vomiting, diarrhoea, and fever are typical symptoms and generally last between three and seven days. Dehydration and shock – potentially resulting in death – are the main risks in severe forms of rotavirus infection and accompany cases of severe diarrhoea (when up to twenty diarrheal episodes per day can occur) (Clark et al., 2017; Esona & Gautam, 2015). There is no specific cure for rotavirus infection, but the consequences of the infection can be managed through administration of fluids and electrolytes, which are key to prevent dehydration. Oral rehydration salts are indicated in mild cases, while intravenous fluid administration is necessary for moderate to severe forms (Parashar, Nelson, & Kang, 2013). A key element in combating rotavirus infection is through implementation of strong hygienic norms, including water and sanitation measures, hand washing, and disinfection of surfaces and objects. Additionally, there is evidence that exclusive breastfeeding – no other food or drink, not even water, except breast milk” (WHO, 2018b, p. 1) in the first six months of life – can protect infants from infection (Krawczyk, Lewis, Venkatesh, & Nair, 2016). To prevent severe rotavirus infections, vaccination is considered as the most cost-effective measure in both low and high-income settings (Abou-Nader et al., 2018; Lamrani, Tubert-Bitter, Hill, & Escolano, 2017), as well as during humanitarian crises (Gargano, Tate, Parashar, Omer, & Cookson, 2015). The WHO recommends vaccination with Rotarix (two doses at 2 and 4 months of age) or RotaTeq (three doses at 2, 4, and 6 months of age). The global coverage of rotavirus vaccine is approximately 28% (WHO, 2018a). Recent efforts to implement vaccination campaigns – particularly in those countries where the higher number of deaths occurs (Okello et al., 2017) – have corresponded to a reduction of the burden of disease (Troeger et al., 2018). Some countries have developed vaccines locally, such as Rotavac, which was developed and introduced in India in 2016. This vaccine recently gained prequalification by the WHO and represents a cheaper alternative to brand drugs and a chance to increase vaccine coverage in low-income settings (PATH, 2018).
Rotavirus in refugee camps
Children living in refugee camps are highly vulnerable due to common water and sanitation issues, poor hygienic conditions, and limited access to health care and immunisation services. Diarrheal diseases, including rotavirus infection, account for 7% of childhood mortality in refugee camps in Africa (Okello et al., 2017). Measures to prevent rotavirus infection in camp settings is thus essential to ensure child health. While poor nutrition may have a negative impact on the immune system, recent studies associate malnutrition with protection from Rotavirus-related diarrhoea. This finding reinforced that improving the nutritional status of children is not sufficient alone to combat Rotavirus infection, highlighting once more the importance of vaccination (Verkerke et al., 2016). Diagnosis of rotavirus infections in contexts of refugee camps and complex emergencies is challenging due to lack of infrastructures (Okello et al., 2017). When health care practitioners cannot make a specific diagnosis, they may prescribe antibiotics as a default treatment. Unfortunately, antibiotic over-prescription in resource-limited settings is described in the literature and can exacerbate antimicrobial resistance (Risk et al., 2013). Rapid diagnostic tests can support health workers in the early diagnosis of rotavirus infections in settings where laboratory confirmation is not available, preventing further transmission of the virus and antibiotic misuse. For point-of-care diagnostic tools to be most effective, they should satisfy the WHO ASSURED requirements (affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free, deliverable) (Okello et al., 2017). Epidemic peaks have been described in the winter season in countries with temperate climates, but these patterns vary across the globe, and the underlying mechanism supporting transmission is unclear (Patel et al., 2013). Information regarding yearly prevalence of rotavirus infection in refugee camps is limited. A surveillance conducted in the Dadaab refugee camp (Kenya) found that the disease was present all year round (Ope, Ochieng, Tabu, & Marano, 2014).
Rotavirus and vaccination among migrants
Information regarding rotavirus immunisation among migrants living in western countries is limited. A study conducted in the United States suggested lower vaccination rates among foreign-born compared to native-born children for several vaccines, including rotavirus (Varan et al., 2017). Cooperation between countries of origin, transit and destination is crucial to implement effective immunisation plans. In particular, the development of online systems to share immunisation records between countries may improve coverage and efficiency (Giambi et al., 2017; WHO-UNHCR-UNICEF, 2015b). Agencies working in migration contexts maintain that vaccinations should be promoted among immigrants, regardless of their legal status (WHO-UNHCR-UNICEF, 2015a). Vaccination is not recommended at the time of border crossing but should occur according to the host country immunisation schedules.
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